2171 East View Parkway • Conyers • Georgia • 30013-5756
Phone: 770-388-5757 or 1-866-374-0788 Fax: 678-413-4227
eMail: leanna@gfpf.org Web Site: www.gf
pf.org
mEMBER INFO
I hereby designate the above individual as my Named Beneficiary who shall receive any benefits as prescribed by law in the event of my death.
I hereby revoke any and all previously named individuals as my Named Beneficiary.
I further elect to revoke all optional benefits previously selected and filed by me under the Georgia Firefighters' Pension Fund's Election of Optional
Benefits document(s).
I h
ereby request the Georgia Firefighters' Pension Fund to take the action set forth in this form.
Change of Beneficiary
(Please Prin
t)
Member No: ___________________ or Social Security No: __________________________
Last Name: ____________________________________________ First: ______________________________ Middle: __________________________
Home Mailing Address: ______________________________________________________________________________________________________
City: _____________________________________________________________________ State: _____________________ Zip: __________________
Email: ________________________________________________________________
Phone(H): _______________________________ Phone(W): _______________________________ Phone(C): _______________________________
Member Info
Beneficiary Info
Georgia Firefighters' Pension Fund
REV. 03/16
____________________________________________________________
Signature of Member
___________________________________________________________
Date
Must Submit Original Forms, Fax Copies Not Accepted
This form is to be used to notify the Fund Office of a change in your beneficiary prior to retirement.
Last Name: ____________________________________________ First: _____________________________ Middle: _________________________
Home Mailing Address: _____________________________________________________________________________________________________
City: ___________________________________________________________________ State: _____________________ Zip: __________________
Phone(H): ______________________________ Phone(W): _______________________________ Phone(C): _______________________________
Social Security No: __________________________ Date of Birth: _______/_______/________ Gender: Male Female
Relationship: __________________________________________________ Email: __________________________________________
Sworn to and subscribed before me
this_________day of __________________,________.
_____________________________________________
Signature of
Notary Public & Seal
_____________________________________________
My Commission Expires On
